It is estimated that 361,946 births occur daily around the world, which corresponds to 251 every minute. The experience of mothers is lived in a completely different way. And although the popular idea is of a moment of love and happiness, thousands of women face a little talked about but extremely frequent phenomenon: obstetric violence. This term, although unknown to some, is an everyday reality on a global level that is not only a medical problem, but also entails a violation of human rights.
What is obstetric violence?
Obstetric violence is defined as mistreatment and abuse that occur in the contexts of prenatal, intrapartum, and postnatal care. It is made up of a wide spectrum of actions ranging from dehumanized treatment to unnecessary medical interventions, which can present as verbal, physical, emotional abuse or loss of a woman’s autonomy over her body.[1]
The term obstetric violence has not been universally recognized and is rejected by several societies. It is not even accepted by the World Health Organization (WHO) because it may involve a deliberate act of violence by healthcare providers, calling into question their ethics and honor. These societies prefer to use “obstetric abuse,” which may not be malicious.[2,3]
As mentioned, obstetric violence makes up a wide spectrum of actions. Examples of these range from denial of analgesia despite the mother’s request, performing repeated vaginal examinations without justification, intimidation to accept medical or surgical procedures, denial of a companion during childbirth, Kristeller maneuver, unjustified separation from the baby , preventing skin-to-skin contact, to verbal humiliation with derogatory comments or ridicule during the birth process.[2]
In high-income countries such as the United States and some European countries, obstetric violence can be found in more subtle and difficult to identify forms because it is justified in the name of safety and hospital quality. Examples of this are excessive use of oxytocin to induce or accelerate labor, number of unnecessary cesarean sections for the convenience of medical personnel, etc.[2]
Types of obstetric violence
Several types of obstetric violence are recognized, which include:[4]
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Verbal violence: use of rude, derogatory, humiliating and discriminatory phrases, for example: “Shut up and push the baby”, “If you continue screaming, your baby will drown”… among others.
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Physical violence: performing unnecessary examinations or examinations, routine use of episiotomies, cesarean sections without medical indication, use of the Kristeller maneuver, salpingoclasis without maternal authorization, performing procedures without anesthesia and overcorrective episiorrhaphy, among others.
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Psychological violence: threats, screams, authoritarian speech and intimidation. Attribution of blame to the woman in situations such as fetal suffering or difficulty in pushing during the expulsion period.
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Sexual violence: performing vaginal examinations without gloves, incorrect manipulation of genitals, examinations without the woman’s consent.
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Social discrimination: lack of respect, stigma, prejudice or differential treatment of a mother due to her race/ethnicity, social, economic, marital status, sexual orientation, religion and education, among others.
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Negligence in care: indifferent care, abandonment, postponing care for women undergoing abortion.
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Inappropriate use of procedures and technologies: iatrogenic procedures, such as oxytocin abuse, immobility in bed during labor, inadequate pain management without justification, early clamping of the umbilical cord.
Where does obstetric violence occur?
Obstetric violence is a global health problem that affects women in all regions of the world, although its prevalence varies between countries, populations and socioeconomic strata. In Mexico, a 2016 study revealed that 33.3% of the women surveyed reported having suffered obstetric violence during their last birth, with the most common forms being physical and verbal abuse and lack of informed consent for medical and surgical procedures.[5]
Alarming values ranging from 76%, as in Türkiye, to 98%, as in Nigeria and Ethiopia, have been identified in low- and middle-income countries. It is estimated that the figures around the world may be even higher than what is recorded, since many women are unaware of the existence of the term “obstetric violence.”[6]
Although the figures vary, it is a structural manifestation of gender inequality and failures in health systems, which makes it an urgent problem worldwide.
Why does it happen?
There is no single culprit within the broad ecosystem of obstetric violence. However, it is a fact that the health system has flaws that throughout history have allowed this type of actions to be normalized. Sometimes hospitals or health centers do not have the infrastructure or supplies necessary to meet daily demand. In addition, other factors, such as lack of staff and work overload, can exacerbate the problem, resorting to incorrect practices that make patient care easier and faster.[4]
The lack of empowerment of women, particularly young women from low socioeconomic strata, or who are in marginalized societies, favors the presence of violence.[7]
Physical and emotional consequences
Any type of obstetric violence has both physical and emotional consequences in the short and long terms.
On a physical level, unnecessary interventions, such as the Kristeller maneuver, episiotomies without consent, and excessive use of oxytocin, can cause maternal and fetal complications.[2]
On an emotional level, many women experience immediate feelings of humiliation, fear and anxiety during childbirth, which can lead to loss of trust in conventional health systems. This is the main reason why women in Latin America refuse to use health care services again in subsequent pregnancies, which increases the risk of preventable complications and, in turn, perinatal morbidity and mortality.[7]
The emotional impact can be of such magnitude that it could cause post-traumatic stress disorder and postpartum depression, affecting the maternal-fetal bond and perhaps causing the interruption of breastfeeding.[8,9]
What can be done to avoid it?
As we have reviewed, a change to end these types of practices is an urgent need, however, it requires a multifactorial effort. Firstly, one of the most important, empowering women through education about their rights during childbirth to identify and report eventualities experienced. The ability to make informed decisions about your birth and your own body must be protected and promoted.[2,3]
Likewise, hospitals and health centers must adopt zero-tolerance policies towards obstetric violence through continuous evaluation of staff and promote training based on respect for patient autonomy. Doctors should view childbirth as an experience in which their role is one of support and guidance.[2,3]
Finally, public policies that protect the rights of women during childbirth must be implemented and monitored constantly and effectively. It is essential that institutions have the necessary material and personnel to meet quality standards in the medical field.[2,3]
During our training we had to witness obstetric violence, without naming it as such, without knowing it in depth, but we lived it together with the patients; abuse so normalized that it sometimes goes unnoticed, making it difficult to recognize and, therefore, to find solutions. On the other hand, the fear of reporting such acts and the consequences that this may entail favors the continuity of these attacks.
For this reason, with this article we invite you to reflect on the following questions: Could you recognize obstetric violence? Have you ever witnessed it? Have you done these practices?
Dr. Jesica Naanous Rayek is a specialist in internal medicine, graduated as a surgeon from the Universidad Anáhuac México Norte and is currently part of the medical group at the ABC Medical Center in Mexico City, Mexico. She is passionate about teaching and being able to transmit her knowledge, which she has achieved with the help of her Instagram. You can also follow her on Facebook and TikTok.